One of the most difficult aspects of healthcare involves the care and treatment of victims of sexual assault and rape. But, any physician who provides healthcare to women should be prepared to provide services to victims of these terrible crimes, according to the American College of Obstetricians and Gynecologists (ACOG).
Sexual assault and rape are widespread in the United States, and they impact every corner of society. Each year, nearly 1.5 million rape-related physical assaults occur in the United States, with one in five women reporting that they have suffered a completed or attempted rate, according to ACOG. Rape disproportionately affects young and minority populations.
Let’s review some guidance on how the clinician can manage rape and sexual assault, starting with definitions. Please note: The scope of this article covers only female sexual assault, not male and child forms.
Sexual assault vs rape
Although used synonymously, the terms rape and sexual assault vary by state law. Sexual assault is a violent and aggressive crime that involves a range of sexual activities. It can take the form of sexual coercion, kissing, and fondling. According to the FBI, rape involves any degree of nonconsensual penetration of the anus or vagina with any body part or object. It can also refer to oral penetration without consent. Sexual assault and rape can include acquaintance rape, date rape, statutory rape, and more.
The destruction that rape causes is severe in both short- and long-term physical and psychological terms. Immediate injuries include scratches, bruises, fractures, and lacerations. Traumatic injuries of the vulva and/or vagina can require surgery.
The risk of injury increases if the perpetrator is a current or former intimate partner, and if the rape occurs in the victim’s or perpetrator’s home. Use of drugs and alcohol, as well as threats with a gun, knife, or another weapon also increase the risk of injury. The rate of pregnancy due to rape is 5%, with about 32,000 such pregnancies documented each year, notes the ACOG.
From a psychological perspective, the victim of sexual assault or rape can often lose control during the crime. Rape-trauma syndrome often happens afterward. The first phase is the acute/disorganization phase and may last from days to weeks. It is marked by pain, eating disturbance, and emotional reactions such as anger, fear, guilt, humiliation, and more. The second phase is the delayed/organization phase which involves flashbacks, nightmares, phobias, and gynecological symptoms. It can be life-altering, and it can transpire weeks or months after an event.
A long-term consequence is post-traumatic stress disorder (PTSD), which involves avoidance, hyperarousal, and a re-experiencing of the trauma. It may take months or years for symptoms to appear.
Role of the physician
The management of sexual assault and rape must be carried out efficiently, according to ACOG. “Early identification of survivors of sexual assault can lead to prevention of long-term and persistent physical and mental health consequences of abuse.
When a history of sexual abuse is disclosed, the clinician can expect that various health care procedures, such as pelvic, rectal, breast, and endovaginal ultrasonographic examinations, may trigger panic and anxiety. Such reactions may stem from PTSD and may have a connection with more remote events.
Patients with a history of sexual assault should be screened for substance use disorder, and those with substance use disorder should be screened for a history of sexual assault, according to ACOG. In one survey of women seeking treatment for substance abuse, the prevalence rate of a history of rape was 64.2%.
Referral for counseling can help provide the patient with insights into their psychological/physical responses to curb later symptoms. Clinicians should provide continuity of care to ensure treatment of long-term symptoms.
When assessing victims of rape or sexual assault during the acute phase, it is important to follow medical and legal requirements with regard to evidence-gathering kits.
The trauma-informed framework acknowledges the impact of trauma on the patient, as well as related signs and symptoms. It is a model that the clinician should follow, per ACOG. The clinician should respond by synthesizing knowledge of trauma into practice to mitigate retraumatization.
Key aspects of this model include ensuring physical and emotional safety, facilitating trustworthiness, promoting patient choice and empowerment, and advising peer support. This model can strengthen the patient-doctor relationship as well as boost health outcomes and minimize chronic repercussions of sexual assault and rape.
Role of the community and hospital
According to the American College of Emergency Physicians (ACEP), the management of sexual assault victims is multifaceted and involves various stakeholders, which the provider should bear in mind. Community plans reflect input from law enforcement agencies, courts, and hospitals within a county or state. Personnel should be capable and trained with access to necessary equipment and diagnostics.
“Each community plan should address the medical, psychological, safety, and legal needs of the sexually assaulted patient,” according to the ACEP. “The plan should provide for counseling, and should specifically address pregnancy and testing for and treatment of sexually transmissible diseases, including HIV.” Importantly, victims of sexual assault should be offered prophylaxis for STIs and pregnancy.
In particular, hospitals may choose to treat victims of sexual assault in a separate facility that specializes in such care.
The American Association of Family Practitioners (AAFP) offers its own guidance on helping victims of sexual assault. In an article published in Family Practice Management, the authors wrote: “Physicians need to be prepared for patients to disclose a history of sexual assault and respond to patients in an empowering, compassionate manner. How physicians respond to disclosure of sexual assault matters. You can be most helpful by providing emotional support, offering resources, and reassuring patients the assault wasn't their fault.”
Finally, the authors cautioned against using physical touch to comfort these victims because it is unknown how these patients will respond. Instead, it’s important for clinicians to be mindful of their tone of voice, words, and body language when providing compassionate care.